Tag Archives: insurance

Who Is Your Doctor?: Choice of Doctor Under Worker’s Compensation

A common dilemma faced by many injured workers: where to seek treatment following a work injury. Some employers force injured workers to a designated medical provider and many times the injured worker continues treatment with that provider. Workers often assume they cannot switch or see their own physician (which is not correct). Treatment at the employer-designated provider continues until the injured worker is sent back to work, even if the injured worker has not fully healed, which can lead to further injury or employment consequences.

Workers can receive treatment from their own doctor following a work injury.  An injured worker in Wisconsin has a right to two “choices” of treating practitioners. What constitutes a “choice” is defined in Wisconsin Statute §102.41(2)(a) and includes any physician, chiropractor, psychologist, dentist, physician assistant, advanced practice nurse practitioner, or podiatrist. The important aspect of physician choice is that referrals from one doctor to another do not exhaust a choice.    

We frequently receive calls from injured workers who believe that a referral from their primary care doctor to an orthopedic doctor is the second choice. But that is not how the law works.  Only if the injured worker leaves the referral chain do they use their “second choice.” 

A referral from a primary care physician to an orthopedic doctor is a single choice. If the orthopedic doctor refers to a pain management physician, again, it is a single choice. The injured worker has now seen three doctors (Primary Care, Orthopedic, Pain Management), but is still within the same “choice.”  Doctors within the same practice count as a single choice. 

Injured workers need to be aware of their options. Insurance companies may designate a referral to an Orthopedic doctor as the “second opinion” and therefore, the second choice, when really this is still only a single choice. This crucial distinction affords the injured worker the opportunity to receive quality care. 

What happens in an emergency? The employer may arrange for emergency treatment after which the injured worker can choose their own doctor without using a choice. This common-sense provision allows employers to direct emergency care without sacrificing the worker’s choice of quality care in the future. 

The best advice for injured workers is to always obtain a referral from a treating doctor to any other doctor or specialist.  In Wisconsin, the injured worker – not the employer or the worker’s compensation insurance company – controls treatment.

Cost Shifting: Worker’s Compensation Dirty Little Secret

Today I taught worker’s compensation “Offsets” in the course I teach at Marquette Law School. The students were aghast at the amount of “cost shifting” that occurs in worker’s compensation: that is, medical costs paid by a variety of sources other than worker’s compensation for medical expenses that should be paid by the worker’s compensation insurer.

We all pay an additional price for medical costs borne by group health insurance carriers, Medicaid, and Medicare that should in fact be paid by worker’s compensation insurers. This “cost shifting” occurs in two significant ways. First, if the claim is denied by the worker’s compensation insurance carrier, medical costs may be paid by the worker’s group health insurance or other private insurance company, or through State Medicaid or federal Medicare programs (the cost of which we all pay in taxes). When those claims are settled, the worker’s compensation insurer routinely saves money by reduced negotiated payment contracts with medical providers, between the provider and the group health carrier, Medicare, or Medicaid (rather than the “full boat” payments that should be paid by the worker’s compensation insurer). If the treatment is deemed work-related after a hearing, the worker’s compensation insurer will pay the other insurer, but at reduced rates.

Second, since only about one in ten cases involves any kind of litigation, workers who are not represented routinely bill their group or other insurance carrier for medical treatment that should be paid by worker’s compensation. Bolstering this notion is a recent article in the Insurance Journal. In the article Jonathan Gruber, Professor of Economics at M.I.T. was quoted indicating that worker’s compensation carriers should see fewer claims as a result of more Americans obtaining health insurance under the Affordable Care Act. He said “As more people have health insurance there is less need for them to have injuries covered by worker’s compensation and this should lower worker’s compensation costs.” Nowhere in this analysis is the notion that the appropriate payor for a worker’s compensation injury should be a worker’s compensation insurer, not health insurance premiums (which are shared by us all) nor Medicare and Medicaid (again shared by us all in the form of taxes).

Workers hurt on the job should have their medical treatment paid by the worker’s compensation insurer, who has received a premium for that risk from the worker’s employer. Cost shifting may increase worker’s compensation profits, but it hurts both the employers’ and the employees’ bottom line.

Medical Care Politics in Worker’s Compensation

The mythology surrounding employee fraud in worker’s compensation is pervasive. Many of my clients begin their conversations with me indicating the following: “I’m not one of those folks faking their worker’s compensation claim.”  The exaggerated media publicity concerning employee fraud has also resulted in outright worker intimidation regarding filing a claim. I had this conversation today with a prospective client.

Attorney: Why didn’t you report the incident?
Client: I didn’t want to have that on my record.  Nobody will hire me if I have a worker’s comp injury.
Attorney: Why didn’t you seek medical treatment?
Client: I do not have insurance.
Attorney: Can you obtain insurance under the Affordable Care Act?
Client: You mean Obamacare?  No way!

Fear of being stigmatized as a complainer, whiner, or simply a recipient of worker’s compensation benefits has prompted many legitimately injured workers from filing a worker’s compensation claim.

The adverse publicity concerning the Affordable Care Act (and its pejorative popular name “Obamacare”) results in many otherwise qualified workers from obtaining the health care they need, especially when denied by a worker’s compensation insurance carrier. 

The politics of medical care intrudes in the worker’s compensation arena daily.